It’s good to keep a list, else you forget there’s more to Twitter than outraged mobs misunderstanding sarcasm.

• More tweets = more citations (says more about the academic enterprise than about Twitter if you ask me).
• Vincent Rajkumar on the trials (haha) and tribulations of starting a randomized clinical trial in the US.
• Should we add courses on dealing with medical insurance to the medical school curriculum? No.
• The no-meeting crowd is good company to be in (as long as we don’t meet!)
• World’s prettiest libraries (with only one clunker on the list).

The decade in which one’s three children are born will have to rank among the best ones ever, no matter what else happened. But then add marriage, a move to America¹, completing 25 years of training², getting a dream job, becoming an uncle — twice — and not to forget, starting this blog, and, well, it is hard to imagine things getting any better.

So yes, it has been a good ten years. Certainly better than any other ten-year span I’ve had. A good test would be imagining the ten-year-ago me learning the outcome of the single decision he’s made back in 2008 to go for residency training in the US of A instead of a PhD in Germany, and I’m not one to pee their pants from excitement but I do imagine myself coming close, even without knowing the counterfactual.

Is America the greatest country in the world? It was for me, at the time, even as a visitor³. And it may continue being so for decades to come; I don’t see any competitors coming close.⁴

EconTalk with Russ Roberts is the best interview podcast I’ve listened to, period. Unlike Tyler Cowen Roberts focuses on an issue or two, not the personality being interviewed. He gives fewer if any passes. The effect is that I feel like I’m actually learning about the thing in question, not just getting acquainted with Cowen’s personality du jour. Whether any learning actually takes place at my advanced age is another matter.

My top 5 episodes: - Keith Smith on free market health care - Venkatesh Rao on Waldenponding - Adam Cifu on the case for being a medical conservative - Patrick Collison on innovation and scientific progress - Andrew McAfee on more from less

Honorable mentions: Cowen, Holiday, Hossenfelder, Bertaud

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Conversations with Tyler are as good as ever. This year’s favorites: - Mark Zuckerberg and Patrick Collison - Margaret Atwood - Masha Gessen - Emily Wilson - Ezekiel Emanuel

(Note that the majority are episodes with women - Cowen has Roberts easily beaten here)

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Breaking Smart with Venkatesh Rao I would recommend to anyone who’s enjoyed the above-linked interview Russ Roberts did with Rao on one of the better Breaking Smart essays. It’s 15-20 minutes of Rao performing mental stretching excercises, solo.

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Plenary Session with Vinay Prasad is another podcast that shines with the solo performances, but the interviews aren’t half-bad either. That isn’t a surprise, since this year Prasad has talked to David Steensma, Frank Harrell, Adam Cifu, H. Gilbert Welch, and Clifford Hudis, among others. Sadly, the podcast still doesn’t have a proper website, so I can’t link to any of these episodes directly.

I started the decade childless and am ending it with three, so I have missed most of the 2010s’ pop culture. This includes the entire Transformers franchise and most of the Marvel Cinematic Universe (so, not much missed then?)

• Film: “Get Out”
• Blockbuster/action film: “Spider-Man: Into the Spider-Verse”
• Album: “Hamilton”
• Single: “Rolling in the Deep”
• TV Show: “Veep”
• Single Season: “The Leftovers” season 2
• Book Fiction: “The Dark Forest” (or “Death’s End” if you count the publication of the first Chinese edition, but TDF is superior)
• Book Non Fiction: “Antifragile”
• Athlete of the Decade: The Đoković-Federer-Nadal trio, but if I had to pick one then obviously Đoković.

Movies and music were better in the 2000s, but oh what time to watch TV and follow tennis. It’s too early to judge the books (though it’s telling that my favorite was originally written in 2008).

Residency application season has just started. Many of the applicants, a few of whom I know in person, will be foreign medical graduates, or FMGs, meaning that they are doctors who want to work in the US but are not US citizens. Most FMGs, but not all, will also be international medical graduates — IMGs — meaning that they have graduated from a non-US medical schools. Something called the Education Commision for Foreign Medical Graduates, or ECFMG, acts as their medical school when interacting with most of the sprawling US bureaucracy. These are our personae dramatis, if you will.

Disclosure: I am both an FMG and an IMG, and first began working in the US on an ECFMG-sponsored J1 visa.

America is a net importer of physicians, that much should obvious to anyone who’s ever been in an American hospital. The country depends on FMGs to keep the system running, get the less lucrative specialties, work in underserved areas, etc. Not so obvious is that most FMGs get to America by lying; ICE-approved, foreign-government sponsored lying for sure, but lying nonetheless.

Here are the lies FMGs tell when they come in: that their country has a need for doctors of such-and-such specialty, and/or that their government is sending them to the US for training in the said specialty, and/or that at the end of training they will go back to their country of origin to work in the (sub)specialty they came in to obtain. Those are the three postulates of the J1 physician exchange visa, the very name of which is also a lie as there is no exchange taking place: foreign doctors do come in, but no American doctors come out.

The postulates are incompatible with reality, and imply foreign government competence that just isn’t there in second and third-world countries¹. Because over there, no one is keeping statistics on specialist needs, and if they are there is actually a surplus, and if there isn’t they wouldn’t be able to afford the (sub)specialists once they come back, and if they could then they would be chosen by party or family lines, and you wouldn’t want them in your hospitals anyway.

So to get a J1 visa FMGs need to obtain a letter from their Ministry of Health or equivalent stating the above (the postulates, not the actual truth; I’m sure that in some of those countries people have gone to prison for saying the truth). But is there a functioning Ministry of Health? Does anyone there know that the letter they are supposed to provide about lending a medical graduate and wanting them back is a piece of kabuki theater, and not a commitment to employ that person if and when they come back? And because this letter is supposed to come in a sealed envelope directly from the Ministry to ECFMG: does anyone there speak English? So here are all those FMGs whose main reason to emigrate to America may have been to escape their kleptocratic governments, being dragged into a game of Whom do I bribe next? and Which newspaper do I threaten them with?² by the rules of the country they were hoping was less crooked than their own.

Which is fine for America, because it doesn’t care as long as it gets its steady stream of MDs one way or another. Only it should care because 1) the amount of person-hours wasted is on par with if not greater than the amount spent writing grants, and that one’s a whopper, 2) it relinquishes control over a part of its healthcare to foreign governments, and 3) it introduces an air of subterfuge and deceit at the very beginning of the FMG-USA relationship. I would like to think this is an aberration to be fixed, and not a preview of things to come in other areas of governance.

The process was probably fine 50 years ago, when both demands of the medical system and the influx of foreign doctors were but a fraction of the current monstrosity, when USMLE was taken on paper if you had to take it at all, when it wasn’t so obvious to a non-aligned physician whether they should go to the US or USSR (or Yugoslavia, for that matter) to get more training. But healthcare has changed and so has the world: it’s time do drop the pretense of an exchange, America, and be honest about what’s going on here.

Twitter brings out the worst in people. If your worst is not that bad then power to you, madam, but most of us need to spend an extraordinary amount of energy not to look like sociopaths, or should just stay away. More often than not I choose the latter.

There are good arguments for why you should be on Twitter from both doctors and civilians. On the opposite end there is a whole book dedicated to why you shouldn’t (full disclosure: I haven’t read the book, but did read two accompanying NYT Opinion pieces back before I realized NYT Opinion pieces weren’t worth my time). So clearly there are two opposing points of view, and while I’m sympathetic to the Twitter cheerleaders and their cause, my own experience makes me take pause. Here’s why:

1. No nuance

Note the “madam” reference in the opening paragraph. Here, I have space to explain what I meant: that a well-behaved user on Twitter was more likely to be a woman. An outrage-primed stranger on Twitter just glancing at the post could instead interpret it as an attempt to emasculate the well-behaved male readers. And I forget, is it still kosher to use madam to refer to women? Or is “females” the appropriate term now, never mind that it’s an adjective? At least using “kosher” is not considered cultural appropriation yet. Right?

I don’t like this lack of nuance for two reasons: because I recognize it in myself when I overreact to a tweet and have to stop myself from writing a snarky reply and because writing down short thoughts that are still coherent is much more time-consuming than writing run-on sentences like this one.

2. Ill will

Recall Justine Sacco and the delight with which a Twitter mob tracked her WiFi-less flight across the Atlantic. Twitter mobs are pure minority rule, wherein the minority has a high follower count with an incentive to mobilize them. It is vexing to see someone with 10,000+ followers retweeting — with a snarky comment, of course — a poorly worded tweet that had thus far garnered three likes and no other retweets. No matter the content of the original tweet, and often they’re deranged rantings of an anti-vaccer, doing it to a person with a hundred-fold lower followe count and a thousand-fold lower reach is unethical at best, and dare I say immoral too when the intent of the retweet is nothing more than virtue signaling.

Again, this kills my enthusiasm for Twitter in two ways: the time I spend self-censoring my Eastern European spent-a-decade-under-US-sanctions tendency towards sarcasm, and the time I spend reading, digesting, and ultimately dismissing these worthless posts.

3. Poisoned stream

But isn’t the great benefit of Twitter over mainstream media the ability to choose whom you follow? Yes, but: Twitter the company is doing its best to ruin that by showing you not only retweets, but also those tweets that people you are following liked, and a random tweet here or there that’s been getting attention (as in: a lot of replies, as in: this is probably controversial) which it thinks may cause you to engage (as in: join the conversation, as in: enter the fray). I am not making this up.

So even if you try to keep your time line completely professional and only follow other MDs who post only their high thoughts on the latest randomized trials in the area you’re interested in… Well, you can’t stop them from liking political posts, and you can’t stop Twitter from foisting its algorithm on you.

4. No country for slow thinkers

So what? Just ignore the noise. Cull your follow list to manage input, write quickly and don’t look back to speed up your output. I suspect that’s what many people who are good at Twitter do, and if you can do it too then power to you. What kills it for me is 1) the opportunity cost (as in: I’d rather spend time with my family, and 2) (and this is the main one) I. cannot. write. like. that. This was supposed to be a two-paragraph post written in the subway. Well clearly it’s not.

As I finish writing this, a scientist I’m following has retweeted the FCC chairman’s gripe about the latest Twitter redesign. An MD is retweeting pointless videos. Random biotech factoids fly by my screen, unwanted and uncared for.

• Green, walkable, good coffee, plenty of people on the streets but not crowded. Who knew.
• The Sixth Floor Museum at Dealey Plaza is very well put together, but it has a remarkable story going for it so it would have been hard to mess it up. Making the audio guide non-optional was a good choice. You can easily spend hours and hours in it: we spent 4.
• Dining was good for the price, but I wasn’t blown away by quality at the randomly selected BBQ places. DC’s Federalist Pig was better than anything we’ve had in Dallas, and the Kalua pork we had on Maui was by far the best.
• That last one may not have been a fair comparison, only having three days to check out the restaurant and spending one of three dinners trying out the impossible burger (which was OK, but I’ll take a well-made black bean burger over it any time).
• There is a proper 7-days-a-week farmers’ market that would have reminded me of the one in my home town in Serbia if it weren’t so gentrified (as in, more artisanal coffee stands and hemp candles than produce).
• The hipster breakfast place in downtown Dallas has blue tile and plastic chairs instead of reclaimed wood and old school benches, but don’t let that fool you: they do serve cortados.
• Four stars, will come back.

I don’t like automated posts on personal Twitter accounts, so I’ve created one just for this blog: @8regress. It’s automatic and unmonitored.

As always, there is an RSS feed.

I’m 12 and the family is taking a summer vacation in sunny Pomorie, Bulgaria. It’s on the Black Sea. The ~400-mile drive in my father’s VW Golf (Mk2) takes close to 12 hours, border check and an interlude in Sophia included. It feels longer: it’s a 3-door hatchback and I’m sharing the back seat with my brother and a suitcase. There are enough groceries in the trunk to last us a week.

We arrive in the early morning and look for a place to stay. Airbnb is 16 years away, but there are vacancy signs posted on private residences all around town. We find one that’s half-built: gray building blocks still visible on the outside and concrete stairs with no railings, but the rooms are actually quite nice and the apartment is self-contained. The owner-slash-proprietor is financing the finishing touches by renting it out. My father approves.

The weather is nice and the beach is crowded. I have a perpetual sunburn. We visit Burgas and Nessebar. Dad almost gets scammed out of all of our German marks by a street money changer. I get a photo taken with a yellow-white python around my neck. We eat at home and take evening strolls up and down what goes for a boardwalk in Pomorie. We ocasionally catch a glimpse of live music from accross a hedge. A few people climb a hillock to watch the concert. I try it once and climb right back down: do I want to spend the evening listening to a Boney M. tribute band?

The drive back through Bulgaria feels faster, but that’s because Dad is speeding. We get caught and the policeman pencils something in on a lemon-yellow card. The next time we stop for gas Dad tries to erase it. He succeeds but the card is now a paler yellow where the marking used to be. They notice this at the border and we stay an extra few hours until they let us through. But then we’re in Serbia and close to home and soon I’ll get back to playing Civilization II and Duke Nukem 3D and Quest for Glory IV so who cares what happened and how we got out of it?

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It’s 2019 and I’m the Dad. The family is taking an early summer vacation in sunny Wailea. It’s on Maui. My wife and I take two new credit cards to get enough points to get three tickets for the four of us. A week before the trip we realize I can’t have a 35-pound toddler on me for two 5-hour flights and we buy the fourth ticket. The airline charges for food, so we stock up on snacks to bring on board; I have a Costco membership card in my wallet.

We are in a one-bedrom two-bathroom condo that is bigger than my family home in Serbia. A decorative bowl full of glass balls greets us in the hallway; a large ceramic vase is next to our bed. My wife glances at our jet-lagged toddler, then at me, and I spend the next half-hour lifting fragile items up on top of kitchen cabinets. I go to bed around midnight, which is 6am Eastern Time.

The condo sits next to a golf course and some tennis courts. I don’t play either. There are five beaches within 5 minutes’ driving distance. They are virtually empty save for one, which has a steady stream of snorklers and divers parading up and down. The Costco-chosen guidebook says it’s the best spot on Maui for snorkling lessons, but 18-month-olds can’t snorkle.

The older sibling collects seashells and runs away from waves and builds puddles for the younger one to jump on. She chats up the adults and can carry a conversation better than her dad. We all wear UPF shirts and go through five bottles of Coppertone. We visit Lahaina and Paia and Kihei. We eat at home and take evening strolls through beachside resorts. There are Luaus on every night. The one at the Marriott is there for all to see from a public walkway. It’s the one we attend one night — the pork is good. There is audience participation: children learn the hula, adults blow into a conch shell; one man proposes to his fiance while up on the stage, in front of all us people — it’s a bit corny.

We wake up at 3am and wake up the kids at 4 to drive up a mountain top to see the sunrise. It is 10°C and colder with wind chill, and the sunrise lasts for all of five minutes; the children are not impressed. The other 100 people looking at it seem quite happy. One man proposes to his fiance, on top of that inactive volcano, in front of all us people — it’s quite romantic.

We sign up for an 8-hour van ride up and down a rainforest highway. It takes 12 hours. We are sitting all the way in the back: the older one is sick but doesn’t vomit, the younger one doesn’t say anything but vomits twice. It’s mostly juice and water and doesn’t smell like acid at all so we wipe it up with tissues and wet wipes and don’t ask the driver to stop. The young couple in front of us asks for more air.

The last flight back is a red-eye and the younger one screams for the first hour of the last leg of the journey because i don’t let her play with the restroom faucet. The attendents are out serving drinks so we let her roll around in the back of the plane, head close to the emergency exit door which I eye nervously. They serve us apple juice which she drinks and falls asleep. The older one is excited: there is an Amazon delivery of one toy or another waiting for her back home. She is still tired enough to be sleeping when the plane catches turbulence — the last 3 hours are bumpy. I watch a movie and try to fall asleep.

• Top four South Maui beaches, best one first: Po’olenalena, Keawakapu (a close second), Wailea (only in the afternoons), Mokapu.
• Top guide book is Maui Revealed. NB: Hotel/lodging information is on their app (‎Hawaii Revealed), and that part of the app is free.
• Top place for shopping is Paia, especially if you’re into that 21st century hippie aesthetic that’s popular with Instagram influencers these days (though mine being aware of it means it won’t be popular for much longer).
• There is a notable absence of panhandlers. If there are any homeless, they are indistinguishable from a certain type of tourist. Locals are indifferent to appreciative of your business, but they don’t go out of their way to get you to pay for stuff (which is unlike any other tropical/Mediterranean island I’ve been to, but then again I haven’t been to many).
• The sand sticks to anything and everything. There’s enough of it in the car that I’ll happily pay any extra cleaning fees the rental agency will surely charge.
• Prices at low and mid-scale restaurants are same or just slightly higher than D.C. This does not bode well for D.C.
• There are more veterinarian than human hospitals on Maui.
• The one general hospital on the island is Keiser’s Maui Memorial Medical Center. It looks like they have a heme/onc service with an infusion center, so don’t think I haven’t thought about it.
• Only two days left.